Provider Demographics
NPI:1649302431
Name:JOHNSON, DOROTHY FULLILOVE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:FULLILOVE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:D. MICHELLE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:PO BOX 1012
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:AR
Mailing Address - Zip Code:71711-1012
Mailing Address - Country:US
Mailing Address - Phone:870-725-6393
Mailing Address - Fax:
Practice Address - Street 1:1616 N VINE
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-9740
Practice Address - Country:US
Practice Address - Phone:870-725-6393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2485235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist